Marshfield Care Center: Pharmacy Service Failures - MO
Inspectors found 26 different medications belonging to at least 10 residents sitting unused in the facility's medication storage area. The drugs included powerful antibiotics like ciprofloxacin and cephalexin, diabetes medications, seizure treatments, and blood pressure pills — some dispensed as recently as late October.
One card of topiramate for treating seizures had 10 tablets remaining. A vial of insulin for diabetes control sat unused. Twenty tablets of cephalexin, a bacterial infection treatment, remained in packaging for one resident. Two syringes of Bydureon, a blood sugar medication, were still available for another.
The Director of Nursing told inspectors on November 6 that the medication room "was a mess at the time." She said there were tons of non-narcotic medications that needed to be destroyed, and the cleanup process would take days to complete. She admitted she hadn't had time to handle the required paperwork and destruction procedures.
"It has been a major problem," the nursing director said.
Staff members painted a consistent picture of neglect. The MDS Coordinator called the medication room "a disaster" that had been in that condition for at least a couple of months. The Assistant Director of Nursing said the counter was full of medications needing destruction and confirmed it had been several months since the room was clean and orderly.
A Licensed Practical Nurse explained that the medication room was "currently a mess pending medications to be destroyed," with the nursing managers typically responsible for handling unused drugs. A Certified Medication Tech said the room contained extra over-the-counter medications, refrigerated drugs, and supplies alongside the non-narcotic medications no longer in use.
The facility had experienced some organizational success in the past. The Assistant Director of Nursing mentioned that an RN who worked there for a few months previously had kept the room in order, but that level of organization had deteriorated after the nurse left.
Multiple medications found by inspectors were antibiotics with significant remaining quantities. Inspectors documented 16 tablets of amoxicillin for one resident, 20 tablets of cephalexin for another, and 2 tablets of cefdinir for a third. One resident had both ciprofloxacin and metronidazole cards with multiple tablets remaining, both dispensed in late September.
Other medications included treatments for serious conditions. A 30-tablet card of trazodone for treating depression and sleep disorders sat unused. Thirty tablets of venlafaxine, an antidepressant, remained in packaging. Respiratory treatments and blood pressure medications were also among the unused drugs.
The Interim Administrator acknowledged during the inspection that the medication room should be kept clean and organized, with all unused medications destroyed in a timely manner. This admission came as staff throughout the facility described months of accumulated pharmaceutical waste.
Federal regulations require nursing homes to maintain organized medication storage areas and properly dispose of unused drugs to prevent medication errors and ensure resident safety. The accumulation of dozens of unused medications across multiple residents suggests systemic problems with the facility's pharmaceutical management.
The inspection occurred following a complaint, though the specific nature of the complaint was not detailed in the federal report. Inspectors classified the violation as causing minimal harm or potential for actual harm to some residents.
Staff members consistently described the medication room's condition using terms like "mess," "disaster," and acknowledgments that cleanup would require days of work. The Director of Nursing's admission that she lacked time for required destruction procedures highlighted staffing or prioritization issues affecting basic medication safety protocols.
The unused medications dated back to late September, with some dispensed as recently as late October, indicating the problem had persisted through multiple months of facility operations. Twenty-six different medications across at least 10 residents represented a substantial accumulation of pharmaceutical waste in a single storage area.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marshfield Care Center For Rehab and Healthcare from 2025-11-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
MARSHFIELD CARE CENTER FOR REHAB AND HEALTHCARE in MARSHFIELD, MO was cited for violations during a health inspection on November 24, 2025.
Inspectors found 26 different medications belonging to at least 10 residents sitting unused in the facility's medication storage area.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.